Choosing a combined oral contraceptive pill

Understanding the Interplay Between Premenstrual Dysphoric Disorder (PMDD) and Female Sexual Dysfunction (FSD)

Premenstrual dysphoric disorder (PMDD) is a severe variant of premenstrual syndrome (PMS), categorized as a mood disorder due to marked symptoms of depression and anxiety, compounded with severe physical symptoms. Female sexual dysfunction (FSD) can manifest as low libido, difficulty achieving sexual pleasure, and dyspareunia, causing functional and psychological distress. PMDD and FSD are globally prevalent conditions with postulated biological, psychological, and social associations between them. Nevertheless, sexual dysfunction in PMDD is an important aspect of women's health that has been understudied and has notable methodological limitations. In this narrative review, we summarize the existing literature on sexual function in women with PMDD and PMS, specify the distinctions between PMDD and other general symptoms of PMS, highlight the significance of understanding sexual dysfunction in the female population, and outline some available therapeutic options. Studies show that women frequently experience debilitating sexual distress during the premenstrual phase; however, there is an essential need to formulate standardized tools for definite diagnosis. Selective serotonin re-uptake inhibitors (SSRIs) and combined oral contraceptive pills (COCPs) are approved medications for PMDD, while flibanserin and bremelanotide are effective in treating FSD. However, the potential effects of these treatment modalities on the two comorbid conditions render them inconclusive. Awareness of PMDD and FSD among clinicians and society can allow the implementation of targeted interventions to alleviate the suffering of women and enhance their quality of life.

Oestrogens in oral contraception: considerations for tailoring prescription to women's needs

BACKGROUND

The oestrogenic component of combined oral contraceptives (COCs) has changed over years with the aim of reducing oestrogen-related side effects and risks, whilst maintaining oestrogen beneficial effects, particularly on cycle control.

PURPOSE

To describe the pharmacological profiles of different oestrogens commonly used in COCs to provide insights on contraceptive prescription tailored to women's needs.

RESULTS

All COCs ensure a high contraceptive efficacy. COCs containing the natural oestrogens oestradiol (E2), oestradiol valerate (E2V) and estetrol (E4) have limited impact on liver metabolism, lipid and carbohydrate metabolism, haemostasis and sex hormone binding globulin levels, compared with ethinylestradiol (EE). COCs with E2 and E2V appear also to entail a lower elevation of the risk of venous thromboembolism vs. EE-containing pills. No epidemiological data are available for E4-COC. E2- and E2V-containing COCs seem to exert a less stabilising oestrogenic effect on the endometrium compared with EE-COCs. The E4-COC results in a predictable bleeding pattern with a high rate of scheduled bleeding and minimal unscheduled bleeding per cycle. Based on in vitro and in vivo animal data, E4 seems to be associated with a lower effect on cell breast proliferation.

CONCLUSION

Today various COCs contain different oestrogens. Prescribers must be familiar with the different properties of each oestrogen for a tailored contraceptive recommendation, considering their safety and contraceptive efficacy, as well as women's needs and preferences.

A review of the pharmacology, clinical outcomes, and real-world effectiveness, safety, and non-contraceptive effects of NOMAC/E2

Selecting an appropriate oral contraceptive can be challenging for healthcare professionals due to the abundance of marketed contraceptive options with different clinical and real-world effectiveness and safety profiles. Nomegestrol acetate + 17β-estradiol (NOMAC/E2) is a combined oral contraceptive (COC) that inhibits ovulation by suppressing ovarian function by a 17-hydroxy-progesterone derivative and an estrogen identical to that endogenously produced by the ovaries. This narrative review examines clinical and real-world studies of NOMAC/E2 based on a background literature search using PubMed and Google Scholar. The review outlines the pharmacology of NOMAC/E2, including its progestational activity, pharmacokinetics, and effects on carbohydrate metabolism, lipid metabolism, and coagulation parameters, and summarizes key clinical efficacy and safety data that led to the approval of NOMAC/E2 in Europe, Brazil, and Australia. To help elucidate how NOMAC/E2 clinical trial data translate into a real-world setting, this review describes the effectiveness and safety of NOMAC/E2 in prospective studies that include over 90,000 users (half of whom received NOMAC/E2), outlining its effects on risk of thrombosis, menstrual bleeding patterns, weight, mood, acne, bone health, and patient quality of life. Non-contraceptive benefits of NOMAC/E2 for women with endometriosis, dysmenorrhea, or pre-menstrual dysphoric disorder are also discussed. These data demonstrate that NOMAC/E2 has a long half-life and rapid absorption, is effective at preventing unwanted pregnancies, and exhibits a favorable safety profile in both clinical trials and real-world settings. Importantly, NOMAC/E2 is not associated with increased risk of venous thromboembolism, a major safety concern of healthcare professionals for women receiving hormonal contraceptives. This review highlights NOMAC/E2 as a differentiated option among COCs and could help inform oral contraceptive choice to ultimately improve patient management and outcomes in real-world settings.

Gap in knowledge of health benefits and risks of combined oral contraceptives among Lebanese women

BACKGROUND

Oral Contraceptive Pills (OCPs) are among the most commonly used forms of contraception, but they are associated with several health benefits and risks. This study aims to determine the gap in knowledge of the underlying health benefits and risks of OCPs among Lebanese women and to identify the factors that might influence their beliefs.

METHODS

A questionnaire was completed by 817 Lebanese women aged 18-64 years old and assessed sociodemographic details, medical information, contraceptive practices, knowledge of underlying health benefits and risks, and information needs related to OCPs.

RESULTS

Among the total participants, 41.5% of women reported using OCPs at some point in their lives yet 46.6% denied receiving information about their benefits and 48% denied receiving information about their risks. The mean total OCP knowledge score was 5.70 out of 25, the mean OCP risk knowledge score was 4.09 out of 15, and the mean OCP benefit knowledge score was 0.77 out of 6. Sociodemographic factors associated with greater total knowledge, risk knowledge and benefit knowledge included OCP usage, being a student, confidence in one's knowledge and satisfaction with one's information. Both the total and risk knowledge scores were found to be higher in women who found that receiving information related to OCPs was important. Finally, participants who lived in central governates had greater total knowledge scores, whereas those with higher levels of education and a family history of endometrial cancer demonstrated better benefit knowledge.

CONCLUSIONS

This study highlighted the poor knowledge of health benefits and risks associated with OCP use among Lebanese women and the associated sociodemographic factors that might influence their beliefs.

Female Athletes and the Menstrual Cycle in Team Sports: Current State of Play and Considerations for Future Research

Over the past ten years there has been a dramatic rise in female sport participation and accompanying female professional national leagues across multiple sports, yet research has not followed suit. Although there are known variations between female and male physiology, training protocols in female sport are predominantly underpinned by research undertaken in male athletes. The hormonal variability experienced by women across the menstrual cycle, as well as the menstrual cycle variability between women, may contribute to the complexity of conducting rigorous physiological studies, leading to a paucity of robust sports-specific research that can be confidently applied to female athletes. Moreover, barriers exist in female sport that potentially limit the ability to conduct research, including the lack of full-time programs and limited resources. Recently, there has been increased interest in the potential effects of fluctuations in the female sex hormones, progesterone and oestrogen, on sport performance across different phases of the menstrual cycle. However, current research evaluating the menstrual cycle and physical performance (such as strength, speed, aerobic fitness, and athletes' perception of their performance) have shown inconsistent results. Additionally, methodological design across studies has shown little consistency, making it difficult to draw firm conclusions, which potentially prevents female athletes optimising their physical and sporting performance. It further impacts coaches and sports science researchers in their ability to provide appropriate training recommendations and educational opportunities. It is important to progress in female athlete research with an understanding of how the unique physiology of female athletes may influence their ability to physically perform in their respective sport, which requires representation in sports science research. This paper will provide an overview on current evidence and limitations within menstrual cycle research and provide considerations and directions for future research in this space within team sports.

Efficacy and safety of anti-androgens in the management of polycystic ovary syndrome: a systematic review and meta-analysis of randomised controlled trials

Background

Anti-androgens and combined oral contraceptive pills (COCPs) may mitigate hyperandrogenism-related symptoms of polycystic ovary syndrome (PCOS). However, their efficacy and safety in PCOS remain unclear as previous reviews have focused on non-PCOS populations. To inform the 2023 International Evidence-based Guideline in PCOS, we conducted the first systematic review and meta-analysis investigating the efficacy and safety of anti-androgens in the management of hormonal and clinical features of PCOS.

Methods

We systematically searched MEDLINE, Embase, PsycInfo, All EBM reviews, and CINAHL up to 28th June 2023 for randomised controlled trials (RCTs) examining oral anti-androgen use, alone or in combination with metformin, COCPs, lifestyle, or other interventions, in women of any age, with PCOS diagnosed by Rotterdam, National Institutes of Health or Androgen Excess & PCOS Society criteria, and using a form of contraception. Non-English studies and studies of less than 6 months duration or which used the same anti-androgen regimen in both/all groups were excluded in order to establish efficacy for the clinical outcomes of interest. Three authors screened articles against selection criteria and assessed risk of bias and quality using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Critical outcomes (prioritised during guideline development for GRADE purposes) included weight, body mass index (BMI), irregular cycles, hirsutism, liver function, and quality of life. Random effects meta-analyses were conducted where appropriate. This study is registered with PROSPERO, CRD42022345640.

Findings

From 1660 studies identified in the search, 27 articles comprising 20 unique studies were included. Of these, 13 studies (n = 961) were pooled in meta-analysis. Seven studies had a high risk of bias, nine moderate and four low. Anti-androgens included finasteride, flutamide, spironolactone, or bicalutamide. In meta-analysis, anti-androgens + lifestyle were superior to metformin + lifestyle for hirsutism (weighted mean difference [WMD] [95% CI]: -1.59 [-3.06, -0.12], p = 0.03; I2 = 74%), SHBG (7.70 nmol/l [0.75, 14.66], p = 0.03; I2 = 0%), fasting insulin and fasting insulin: glucose ratio (-2.11 μU/ml [-3.97, -0.26], p = 0.03; I2 = 0% and -1.12 [-1.44, -0.79], p < 0.0001, I2 = 0%, respectively), but were not superior to placebo + lifestyle for hirsutism (-0.93, [-3.37, 1.51], p = 0.45; I2 = 76%) or SHBG (9.72 nmol/l [-0.71, 20.14], p = 0.07; I2 = 31%). Daily use was more effective for hirsutism than use every three days (-3.48 [-4.58, -2.39], p < 0.0001, I2 = 1%), and resulted in lower androstenedione levels (-0.30 ng/ml [-0.50, -0.10], p = 0.004; I2 = 0%). Combination treatment with anti-androgens + metformin + lifestyle resulted in lower testosterone compared with metformin + lifestyle (-0.29 nmol/l [-0.52, -0.06], p = 0.01; I2 = 61%), but there were no differences in hirsutism when anti-androgens + metformin + lifestyle were compared with either anti-androgens + lifestyle or metformin + lifestyle. In limited meta-analyses (n = 2 trials), combining anti-androgens with COCP resulted in poorer lipid profiles compared with COCP ± placebo, with no differences in other outcomes.

Interpretation

Current evidence does not support the use of anti-androgens preferentially to COCPs to treat hyperandrogenism in PCOS. Anti-androgens could be considered to treat hirsutism in PCOS, where COCPs are contraindicated, poorly tolerated, or present a sub-optimal response after a minimum 6-month period, with consideration of clinical context and individual risk factors and characteristics.

Funding

National Health and Medical Research Council (NHMRC) of Australia Monash University.

Online platforms for prescription and supply of hormonal contraception in Australia: a mapping review

Online platforms have emerged as a convenient way for individuals to access contraception. However, the extent to which such services exist in Australia and how they operate is currently unknown. We aimed to identify Australian online contraception platforms and evaluate the services they provide to determine the degree to which they may facilitate equitable access to contraception. We conducted an internet search to identify online contraception platforms operating in Australia. Data were extracted from each of the platforms relating to operating policies, services provided and associated payment processes, as well as prescribing and screening processes for assessing user suitability. As of July 2022, eight online contraception platforms operating within Australia were identified. All platforms offered oral contraception, with two also offering the vaginal ring, and one emergency oral contraception. None of the platforms provided access to long-acting reversible contraception. Significant variability existed in product and membership costs across platforms, with only one platform providing access to subsidised medicines. Five platforms restricted services to those already using oral contraception. Overall, online questionnaires were deemed to be adequately screening for important contraindications to using oral contraception. While online contraception platforms may be a valuable option for some individuals who face access barriers and are willing to pay out-of-pocket for to have their contraception sent straight to their home, they do not necessarily ensure that individuals can access their contraceptive method of choice or address recognised financial and structural barriers to contraceptive care.

Effect of Anthropometric Parameters on Achilles Tendon Stiffness of Professional Athletes Measured by Shear Wave Elastography

BACKGROUND

Shear wave elastography (SWE) is currently used to detect tissue pathologies and, in the setting of preventive medicine, may have the potential to reveal structural changes before they lead to functional impairment. Hence, it would be desirable to determine the sensitivity of SWE and to investigate how Achilles tendon stiffness is affected by anthropometric variables and sport-specific locomotion.

METHODS

To investigate the influence of anthropometric parameters on Achilles tendon stiffness using SWE and examine different types of sports to develop approaches in preventive medicine for professional athletes, standardized SWE of Achilles tendon stiffness was performed in 65 healthy professional athletes (33 female, 32 male) in the longitudinal plane and relaxed tendon position. Descriptive analysis and linear regression were performed. Furthermore, subgroup analysis was performed for different sports (soccer, handball, sprint, volleyball, hammer throw).

RESULTS

In the total study population (n = 65), Achilles tendon stiffness was significantly higher in male professional athletes (p < 0.001) than in female professional athletes (10.98 m/s (10.15-11.65) vs. 12.19 m/s (11.25-14.74)). Multiple linear regression for AT stiffness did not reveal a significant impact of age or body mass index (BMI) (p > 0.05). Subgroup analysis for type of sport showed the highest AT stiffness values in sprinters (14.02 m/s (13.50-14.63)).

CONCLUSION

There are significant gender differences in AT stiffness across different types of professional athletes. The highest AT stiffness values were found in sprinters, which needs to be considered when diagnosing tendon pathologies. Future studies are needed to investigate the benefit of pre- and post-season musculoskeletal SWE examinations of professional athletes and a possible benefit of rehabilitation or preventive medicine.

Contraception knowledge and practices among students in Lebanese universities

This study aimed to evaluate the proportion of contraception users among Lebanese youth, and the extent of knowledge and perception on birth control; and to raise awareness and sensitise young adults to sexual health, which remains taboo in Lebanon. The 30-item questionnaire was broadcasted to students in private and public universities in Lebanon, through social media and it collected information on contraception use and student knowledge. Over 30% of responders were medical students, and 41% have ever used contraceptives (mostly women); among which, 52.1% for contraception versus 47.9% for medical reasons. According to responders, the pill ranked high in terms of effectiveness (72.4% of responders perceive the pill as effective), followed by the male condom (69.1%) and the hormonal intrauterine device (29.6%). Some would not use contraception in the future, for religious reasons (30.8%) or for fear of complications (46.2%); indeed, around a third of contraceptive users (all female) have experienced adverse effects. Finally, students expressed concern about long-term complications of contraceptive use (pulmonary embolism/phlebitis, breast/endometrial/ovarian cancer, stroke, depression and myocardial infarction). Though less frequent than in the Western world, contraception use in Lebanon is non-negligible and gaps in university students' knowledge on contraception were identified; which should prompt sexual education and family planning initiatives in Lebanon.

Hormonal contraceptive prescriptions in the UK Armed Forces

INTRODUCTION

Thirty four per cent of women use hormonal contraceptives in the UK and the contraceptive pill is the most common method. There are no comparable data in the UK Armed Forces, but servicewomen are often required to complete physically arduous job roles in combat zones and may be more likely to take contraceptives to control or stop menstrual bleeding than the general population. We explored the prevalence of hormonal contraceptive prescriptions in the UK Armed Forces.

METHODS

The study used defence medical records (Defence Medical Information Capability Programme) to identify hormonal contraceptive prescriptions for all serving regular UK servicewomen (n=15 738) as of 1 September 2017.

RESULTS

Thirty one per cent of servicewomen (Royal Navy, 28%; British Army, 30%; Royal Air Force, 34%) had a current prescription for a hormonal contraceptive. Non-officer ranks were more likely to have a prescription for a hormonal contraceptive (32%) than officers (27%) (p<0.01). The contraceptive pill was more commonly prescribed (68%) than long-acting reversible contraceptive methods (32%) (contraceptive injection, 11%; contraceptive implant, 11%; intrauterine device, 10%).

CONCLUSION

Prescription data suggest that the prevalence of hormonal contraceptive use in UK servicewomen is comparable with the general UK population. These findings suggest that military service does not influence prevalence or choice of hormonal contraceptives.

Moving beyond the mean: Promising research pathways to support a precision medicine approach to hormonal contraception

Women's psychological and behavioral responses to hormonal contraceptive (HC) treatment can be highly variable. One of the great challenges to researchers seeking to improve the experiences of women who use HCs is to identify the sources of this variability to minimize unpleasant psychobehavioral side-effects. In the following, we provide recommendations for programs of research aimed at identifying sources of heterogeneity in women's experiences with HC. First, we review research demonstrating person- and prescription- based heterogeneity in women's psychobehavioral responses to HCs. Next, we identify several promising person- and prescription- based sources of this heterogeneity that warrant future research. We close with a discussion of research approaches that are particularly well-suited to address the research questions raised in article. Together, this review provides researchers with several promising research pathways to help support the development of a precision medicine approach to HC treatment.

Stiffness of Muscles and Tendons of the Lower Limb of Professional and Semiprofessional Athletes Using Shear Wave Elastography

OBJECTIVE

Shear wave elastography (SWE) allows assessment of muscle and tendon stiffness and can be used to diagnose soft tissue pathologies such as tendinopathies. In sports medicine, SWE may have the potential to uncover structural changes early on before they lead to functional impairment. To systematically analyze possible differences in tendon and muscle stiffness of the lower limb between professional (PG) and semiprofessional female athletes (SG) using SWE and to compile reference values for developing preventive medicine approaches for professional athletes.

METHODS

Standardized SWE of both lower limb tendons and muscles (Achilles tendon [AT], soleus muscle insertion [SM], patellar tendon [PT], quadriceps tendon [QT], vastus medialis muscle [VM]) in the longitudinal plane was performed with the tendons in relaxed position in 24 healthy professional female athletes (PG) in comparison with 24 healthy semiprofessional female athletes (SG).

RESULTS

Median tendon and muscle stiffness was significantly higher in professional athletes (AT:PG, 11.12 m/s vs SG, 7.33 m/s, P < .001; SM: 1.77 m/s vs 1.14 m/s, P < .001; VM: 1.63 m/s vs 0.87 m/s, P < .001; QT: 3.31 m/s vs 2.61 m/s, P < .05). There was no significant difference in patellar tendon stiffness between PG and SG (PT: 2.57 m/s vs 3.21, P = .25).

CONCLUSION

Professional female athletes have higher stiffness values than semiprofessional female athletes in lower limb muscles and tendons, except for the patellar tendon. Knowledge of such differences is necessary for diagnosing tendinopathy and injuries. Musculoskeletal SWE could offer great benefits in sports medicine as well as in rehabilitation and preventive medicine.

Effects of orally administered hormonal contraceptives on the musculoskeletal system of healthy premenopausal women-A systematic review

Introduction

The musculoskeletal system (MSK) is one of the extragonadal target tissues of sex hormones: osteoblasts and osteocytes express estrogen receptors, while in fibroblasts of the anterior cruciate ligament (ACL) and myocytes of the vastus lateralis muscle (MVL), estrogen and progesterone receptors can be detected by immunoassay. Indeed, upon binding of sex hormones to the extragonadal receptors, the MSK seems to respond to varying levels of sex hormones with structural adaptation. Hormonal contraceptives can affect the musculoskeletal system; however, there is a lack of high-quality studies, and no recommendation for female athletes exists.

Material and Methods

This is a systematic review of publications on the effects of oral hormonal contraceptives on the biomechanical properties of tendons, muscles and ligaments, muscle strength, and soft tissue regeneration. A systematic database search was performed using MESH keywords and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology in Pubmed and Cochrane to identify studies investigating the influence of oral hormonal contraceptives on muscles, tendons, and ligaments of healthy, adult, premenopausal women. The risk of bias in the studies included was assessed by two independent researchers using the ROBINS-I Tool.

Results

Nine comparative studies were identified that met the inclusion criteria. Endpoints were muscle strength and biomechanical tissue properties. No significant influence of oral hormonal contraceptives on muscle strength was found, although general muscle growth and Type I fiber growth were found to be significantly increased in a dose-dependent manner. There was a negative effect on regeneration of muscle strength after exercise. The stiffness of tendons remained unchanged, while their size adaptation to load increased.

Conclusion

The anabolic effect could be beneficial for specific sports, whereas reduced muscle regeneration could be disadvantageous for women exercising with high-performance demands. The different effects on tendons and ligaments and the functional consequences of altered ligament and muscle stiffness, especially with regard to synthetic hormones, should be further investigated.

Effects of oral contraceptive use on muscle strength, muscle thickness, and fiber size and composition in young women undergoing 12 weeks of strength training: a cohort study

BACKGROUND

It is suspected that hormonal fluctuations during menstruation may cause different responses to strength training in women who use oral contraceptives (OC) versus those who do not. However, previous studies that investigated the existence of such differences produced conflicting results. In this study, we hypothesized that OC use has no effect on muscle strength and hypertrophy among women undergoing strength training. Thus, we compared the differences in muscle strength and thickness among women who used OCs and those who did not.

METHODS

We investigated the influence of OC use on muscle strength (Fmax), muscle thickness (Mtk), type 1-to-type 2 muscle fiber (NO) ratio, muscle fiber thickness (MFT), and nuclear-to-fiber (N/F) ratio. Seventy-four healthy young women (including 34 who used OCs and 40 who did not) underwent 12 weeks of submaximal strength training, after which Fmax was evaluated using a leg-press machine with a combined force and load cell, while Mtk was measured using real-time ultrasonography. Moreover, the NO ratio, MFT, and N/F ratio were evaluated using muscle needle biopsies.

RESULTS

Participants in the non-OC and OC groups experienced increases in Fmax (+ 23.30 ± 10.82 kg and + 28.02 ± 11.50 kg respectively, p = 0.073), Mtk (+ 0.48 ± 0.47 cm2 and + 0.50 ± 0.44 cm2 respectively, p = 0.888), Fmax/Mtk (+ 2.78 ± 1.93 kg/cm2 and + 3.32 ± 2.37 kg/cm2 respectively, p = 0.285), NO ratio (type 2 fibers: + 1.86 ± 6.49% and - 4.17 ± 9.48% respectively, p = 0.169), MFT (type 2 fibers: + 7.15 ± 7.50 µm and + 4.07 ± 9.30 µm respectively, p = 0.435), and N/F ratio (+ 0.61 ± 1.02 and + 0.15 ± 0.97 respectively, p = 0.866) after training. There were no significant differences between the non-OC and OC groups in any of these parameters (p > 0.05).

CONCLUSIONS

The effects of 12 weeks of strength training on Fmax, muscle thickness, muscle fiber size, and composition were similar in young women irrespective of their OC use.

Thromboembolic safety of norethisterone vs levonorgestrel in combined oral contraceptive users: a pooled analysis of 4 large prospective cohort studies

BACKGROUND

Norethisterone (acetate) and levonorgestrel are marketed globally as components of combined oral contraceptives. Although guidelines recommend both as first-line combined oral contraceptives, no direct, comparative safety studies are available.

OBJECTIVE

We directly compared the thromboembolic event risk associated with the use of norethisterone acetate-containing and levonorgestrel-containing combined oral contraceptives.

STUDY DESIGN

Data regarding the cohorts of interest, norethisterone/norethisterone acetate (ethinylestradiol ≤30 µg) and levonorgestrel (ethinylestradiol ≤30 µg), were retrieved from a pooled dataset comprising 4 prospective, noninterventional, active-surveillance cohort studies in 14 European countries, the United States, and Canada, with similar study design but differing medication cohorts. Baseline characteristics and parameters of reproductive, contraceptive, and medical history were summarized using descriptive statistics. Propensity score subclassification was applied to balance baseline parameters between cohorts. Time-to-event analysis of venous thromboembolic events was performed on the basis of the extended Cox model to calculate crude and adjusted hazard ratios, including 95% confidence intervals. The time of venous thromboembolic events was censored at the end of the observation period for women who did not have an event. Women who dropped out or were lost to follow-up without reported venous thromboembolic events were censored at the time they last confirmed that they did not have an event.

RESULTS

The pooled dataset included 235,437 combined oral contraceptive users who were followed up for a total of 571,163 women years. Among these, 40,142 women were users of norethisterone/norethisterone acetate (ethinylestradiol ≤30 µg), and 39,098 women were users of levonorgestrel (ethinylestradiol ≤30 µg), contributing 61,976 and 84,816 women years of observation, respectively. The observed prevalence of prognostic factors at baseline showed typical features of US and European combined oral contraceptive users. Both cohorts showed a similar, low rate of thromboembolic events, and we could exclude a 1.5-fold increased venous thromboembolism risk for norethisterone/norethisterone acetate relative to levonorgestrel (adjusted hazard ratio, 0.73; 95% confidence interval, 0.48–1.11).

CONCLUSION

These data confirm the similar risk profiles of norethisterone/norethisterone acetate and levonorgestrel regarding thromboembolic events in routine combined oral contraceptive use of around 80,000 women from Europe and the United States/Canada. The analysis provides reassurance for both combined oral contraceptive users and clinicians regarding the safety of oral contraceptives and potentially opens discussion on norethisterone acetate as a potential gold standard therapy in clinical and postmarket research alongside levonorgestrel-combined oral contraceptives.

The Effect of the Menstrual Cycle and Oral Contraceptive Cycle on Muscle Performance and Perceptual Measures

Most reproductive-aged women are exposed to fluctuating female steroid hormones due to the menstrual cycle or oral contraceptive use. This study investigated the potential effect of the menstrual cycle and combined monophasic oral contraceptive cycle on various aspects of muscle performance. Thirty active females (12 with a natural menstrual cycle, 10 taking a high-androgenicity oral contraceptive and 8 taking a low-androgenicity oral contraceptive), aged 18 to 30 years, were tested three times throughout one menstrual or oral contraceptive cycle. Counter-movement jumps, bilateral hop jumps, handgrip strength, isometric knee extensor strength and isokinetic knee flexion and extension were assessed. Perceptual ratings of fatigue, muscle soreness, pain and mood were recorded. Most variables showed no significant changes over the menstrual or oral contraceptive cycle. However, for the menstrual cycle group, isokinetic knee flexion at 240° s⁻¹, and time of flight in bilateral hopping and counter movement jumps showed better results during the mid-luteal phase compared with the late follicular phase. For the high-androgenicity oral contraceptive group, isokinetic knee flexion at 240° s⁻¹ was significantly higher in the late hormone phase compared with the early hormone phase. For the low-androgenicity oral contraceptive group, time of flight for the counter-movement jumps was lower in the late hormone phase compared with the early hormone phase. The findings indicate that faster and explosive aspects of muscle performance may be influenced by endogenous and exogenous female hormones.

Drug Interactions Involving 17α-Ethinylestradiol: Considerations Beyond Cytochrome P450 3A Induction and Inhibition

It is widely acknowledged that drug-drug interactions (DDIs) involving estrogen (17α-ethinylestradiol (EE))-containing oral contraceptives (OCs) are important. Consequently, sponsors of new molecular entities (NMEs) often conduct clinical studies with priority given to OCs as victims of cytochrome P450 (CYP) 3A (CYP3A) induction and inhibition. Such scenarios are reflected in the US Food and Drug Administration-issued guidance documentation related to OC DDI studies. Although CYP3A is important, OCs such as EE are metabolized by sulfotransferase 1E1 and UDP-glucuronosyltransferase (UGT) 1A1, expressed in the gut and liver, and so both can also serve as loci of victim OC DDI. Therefore, for any NME, one should carefully consider its induction and inhibition profile involving CYP3A4/5, UGT1A1, and SULT1E1. As DDI perpetrators, available clinical DDI data indicate that EE-containing OCs can induce (e.g., UGT1A4 and CYP2A6) and inhibit (CYP1A2 ≥ CYP2C19 > CYP3A4/5 > CYP2C8, CYP2B6, CYP2D6, and CYP2C9) various CYP forms. Although available in vitro CYP inhibition data do not explain such a graded inhibitory effect in vivo, it is hypothesized that EE differentially modulates CYP expression via potent agonism of the estrogen receptor expressed in the gut and liver. From the standpoint of the NME as potential OC DDI victim, therefore, it is important to assess its projected (pre-phase I) or known therapeutic index and pharmacokinetic profile (fraction absorbed, absolute oral bioavailability, clearance/extraction class, fraction metabolized by CYP1A2, CYP2C19, CYP2A6, and UGT1A4). Such information can enable the prioritization, design, and interpretation of NME-OC DDI studies.

The acute effect of the menstrual cycle and oral contraceptive cycle on measures of body composition

PURPOSE

This study aimed to investigate the effect of fluctuating female hormones during the menstrual cycle (MC) and oral contraceptive (OC) cycle on different measures of body composition.

METHODS

Twenty-two women with a natural MC and thirty women currently taking combined monophasic OC were assessed over three phases of the menstrual or oral contraceptive cycle. Body weight, skinfolds, bioelectric impedance analysis (BIA), ultrasound, dual-energy X-ray absorptiometry (DXA), and peripheral quantitative computed tomography (pQCT) measurements were performed to assess body composition. Urine specific gravity (USG) was measured as an indication of hydration, and serum oestradiol and progesterone were measured to confirm cycle phases.

RESULTS

Five participants with a natural MC were excluded based on the hormone analysis. For the remaining participants, no significant changes over the MC and OC cycle were found for body weight, USG, skinfolds, BIA, ultrasound and pQCT measures. However, DXA body fat percentage and fat mass were lower in the late follicular phase compared to the mid-luteal phase of the MC, while for the OC cycle, DXA body fat percentage was higher and lean mass lower in the early hormone phase compared with the late hormone phase.

CONCLUSION

Our findings suggest that assessment of body fat percentage through BIA and skinfolds may be performed without considering the MC or OC cycle. Body adiposity assessment via DXA, however, may be affected by female hormone fluctuations and therefore, it may be advisable to perform repeat testing using DXA during the same phase of the MC or OC cycle.

Development of Hormonal Intravaginal Rings: Technology and Challenges

Intravaginal rings (IVRs) are minimally invasive polymeric devices specifically designed to be used for the sustained and prolonged release of various type of drugs such as hormones. One of the benefits of using topical drug delivery systems (e.g., IVRs) is the fact that systemic drug delivery may cause drug resistance due to elevated drug levels. Topical drug delivery also provides higher concentrations of the drug to the target site and has fewer side effects. In addition, when a drug is administered vaginally, the hepatic first-pass effect is avoided, resulting in higher absorption. Contraception and treatments for specific diseases such as endometriosis and hormone deficiencies can be improved by the administration of hormones via an IVR. This article aims to classify and compare various designs of commercially available and non-commercial hormonal IVRs and to analyze their performance. Current challenges affecting the development of IVRs are investigated, and proposed solutions are discussed. A comprehensive search of publications in MEDLINE/PubMed and of commercial product data of IVRs was performed, and the materials, designs, performance, and applications (e.g., contraception, endometriosis, estrogen deficiency and urogenital atrophy) of hormonal IVRs were thoroughly evaluated. Most hormonal IVRs administer female sex hormones, i.e., estrogen and progestogens. In terms of material, IVRs are divided into 3 main groups: silicone, polyurethane, and polyethylene-co-vinyl acetate IVRs. As regards their design, there are 4 major designs for IVRs which strongly affect their performance and the timing and rate of hormone release. Important challenges include reducing the burst release and maintaining the bioavailability of hormones at their site of action over a prolonged period of administration as well as lowering production costs. Hormonal IVRs are a promising method which could be used to facilitate combination therapies by administering multiple drugs in a single IVR while eliminating the side effects of conventional drug administration methods. IVRs could considerably improve womenʼs quality of life all over the world within a short period of time.

Thromboembolic safety profile of low-dose estradiol (valerate) in combined hormonal preparations: Implications for the development of new hormonal endometriosis and uterine fibroid therapies

Background:

Several promising new medications containing low-dose estradiol (E2) in combination with a progestin and an additional component, such as gonadotropin-releasing hormone antagonists, are currently being developed for use in pre-menopausal women.

Objective:

This pooled analysis was designed to estimate the thromboembolic safety profile of E2 and its ester, estradiol valerate (E2Val), when used in combined hormonal treatments in a pre-menopausal population.

Methods:

Data regarding users of combined oral contraceptives (COCs) and combined menopausal hormonal therapy (MHT) containing either E2/E2Val or ethinylestradiol (EE) ⩽ 30 µg were retrieved from five large prospective, non-interventional, cohort studies in Europe, US, and Canada with similar study design but differing medication cohorts. Propensity score sub-classification was applied to balance baseline parameters between cohorts and time-to-event analysis of venous thromboembolic events (VTE) was carried out based on the extended Cox model to calculate crude and adjusted hazard ratios (HR).

Results:

(1) Crude incidence rates of VTE were higher in MHT users compared to pre-menopausal COC users, (2) the VTE risk in menopausal users of E2/E2Val-norethindrone acetate was not higher than that in menopausal users of E2/E2Val-progestin (adjusted HR 0.71; 95% confidence interval, 0.41-1.26) and (3) the VTE risk in pre-menopausal users of E2/E2Val-progestin was similar, or lower, than pre-menopausal users of EE⩽30µg-progestin (adjusted HR 0.49; 95% confidence interval, 0.28–0.84).

Conclusion:

Our data presents a solid safety assessment of combined hormonal preparations containing E2/E2Val. We conclude that the risk of E2/E2Val-norethindrone acetate in pre-menopausal users is unlikely to be higher than the known risk of COCs containing EE ⩽ 30 µg-progestin.

Influence of hormonal contraceptives on peripheral vascular function and structure in premenopausal females: a review

Hormonal contraceptives are one of the most widely used prescriptions for premenopausal women worldwide. Although the risk of venous and arterial cardiovascular events (e.g., deep vein thrombosis, arterial clotting) with hormonal contraceptives, specifically oral contraceptive pills, has been established, the literature on early risk indicators, such as peripheral vascular structure and function has yet to be consolidated. The purpose of this review is to summarize literature examining the impact of different hormonal contraceptives on vascular function and structure, including consideration of phasic differences within a contraceptive cycle, and to propose future directions for research. It is evident that hormonal contraceptive use appears to impact both macrovascular and microvascular endothelial function, with phasic differences in some contraceptive types dependent on progestin type, the ratio of ethinyl estradiol-to-progestin, and route of administration. However, hormonal contraceptives do not appear to impact smooth muscle function in the macrovasculature or microvasculature, arterial stiffness, or vascular structure. Underlying mechanisms for observed impacts and areas of future research are discussed. This review provides timely consolidation of research examining hormonal contraceptives and peripheral vascular function and structure and provides guidance on considerations for hormonal contraceptive use in study design.

The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis

BACKGROUND

Oral contraceptive pills (OCPs) are double agents, which downregulate endogenous concentrations of oestradiol and progesterone whilst simultaneously providing daily supplementation of exogenous oestrogen and progestin during the OCP-taking days. This altered hormonal milieu differs significantly from that of eumenorrheic women and might impact exercise performance, due to changes in ovarian hormone-mediated physiological processes.

OBJECTIVE

To explore the effects of OCPs on exercise performance in women and to provide evidence-based performance recommendations to users.

METHODS

This review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A between-group analysis was performed, wherein performance of OCP users was compared with naturally menstruating women, and a within-group analysis was conducted, wherein performance during OCP consumption was compared with OCP withdrawal. For the between-group analysis, women were phase matched in two ways: (1) OCP withdrawal versus the early follicular phase of the menstrual cycle and (2) OCP consumption versus all phases of the menstrual cycle except for the early follicular phase. Study quality was assessed using a modified Downs and Black Checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation working group. All meta-analyses were conducted within a Bayesian framework to facilitate probabilistic interpretations.

RESULTS

42 studies and 590 participants were included. Most studies (83%) were graded as moderate, low or very low quality, with 17% achieving high quality. For the between-group meta-analysis comparing OCP users with naturally menstruating women, posterior estimates of the pooled effect were used to calculate the probability of at least a small effect (d ≥ 0.2). Across the two between-group comparison methods, the probability of a small effect on performance favouring habitual OCP users was effectually zero (p < 0.001). In contrast, the probability of a small effect on performance favouring naturally menstruating women was moderate under comparison method (1) (d ≥ 0.2; p = 0.40) and small under comparison method (2) (d ≥ 0.2; p = 0.19). Relatively large between-study variance was identified for both between-group comparisons ([Formula: see text]0.5 = 0.16 [95% credible interval (CrI) 0.01-0.44] and [Formula: see text]0.5 = 0.22 [95% CrI 0.06-0.45]). For the within-group analysis comparing OCP consumption with withdrawal, posterior estimates of the pooled effect size identified almost zero probability of a small effect on performance in either direction (d ≥ 0.2; p ≤ 0.001).

CONCLUSIONS

OCP use might result in slightly inferior exercise performance on average when compared to naturally menstruating women, although any group-level effect is most likely to be trivial. Practically, as effects tended to be trivial and variable across studies, the current evidence does not warrant general guidance on OCP use compared with non-use. Therefore, when exercise performance is a priority, an individualised approach might be more appropriate. The analysis also indicated that exercise performance was consistent across the OCP cycle.

Practice does not make perfect: A brief view of athletes' knowledge on the menstrual cycle and oral contraceptives

OBJECTIVES

To assess the knowledge of Australian elite female athletes surrounding the menstrual cycle and oral contraceptives.

DESIGN

Cross sectional survey.

METHODS

Australian female athletes (n=189) representing their state and/or country in their respective sport completed a questionnaire comprising questions (multiple choice and short answer) relating to the menstrual cycle and oral contraceptives. A knowledge 'score' was calculated by allocating one point for each correct answer; the highest knowledge score that could be achieved was 14. Linear regression analysis was used to identify variables that were independently associated with menstrual cycle and oral contraceptive knowledge.

RESULTS

Almost half (47.1 %) of the athletes surveyed were currently using hormonal contraception, the majority (75.3 %) of which used an oral contraceptive pill. Nevertheless, the mean knowledge score achieved by athletes on the questionnaire was 5.03±3.06, with only 8.5 % of athletes achieving a knowledge score of 10 or above. Hormonal contraceptive use and 'identifying as an individual athlete' were two factors that were significantly associated with overall knowledge score (p≤0.004), with current hormonal contraceptive users and individual athletes scoring 1.79 and 1.66 points on average higher than non-users and team sport athletes, respectively.

CONCLUSIONS

Our findings indicate that knowledge surrounding the menstrual cycle and oral contraceptives was low in most elite athletes. Further education is warranted to enable athletes to make informed decisions regarding hormonal contraception, and any educational interventions should be implemented across all athlete groups.

Herbal supplements interactions with oral oestrogen-based contraceptive metabolism and transport

The increased use of herbal supplements as complementary or alternative medicines has become a clinical conundrum due to the potential for herb-drug interactions. This is exacerbated by an increased supply of new herbal supplements in the market claiming various health advantages. These herbal supplements are available as over-the-counter self-medications. Herbal supplements are generally perceived as efficacious without side effects commonly associated with conventional drugs. However, despite regulations, claims related to their therapeutic effects are mostly unsupported by scientific evidence. These products often lack suitable product quality controls, labelled inadequately and with batch to batch variations, potentially compromising the safety of the consumer. Amongst health practitioners, the greatest concern is related to the lack of chemical characterization of the active compounds of the herbal supplements. The interaction between these different active components and their concomitant effects on other conventional drugs is generally not known. This review will focus on herbal supplements with the potential to effect pharmacokinetic and pharmacodynamic properties of oestrogen-based oral contraceptives. The use of herbal supplements for weight management, depression, and immune boosting benefits were selected as likely herbal supplements to be used concomitantly by women on oral contraceptives.

The Effect of the Menstrual Cycle and Oral Contraceptives on Acute Responses and Chronic Adaptations to Resistance Training: A Systematic Review of the Literature

BACKGROUND

Resistance training is well known to increase strength and lean body mass, and plays a key role in many female athletic and recreational training programs. Most females train throughout their reproductive years when they are exposed to continuously changing female steroid hormone profiles due to the menstrual cycle or contraceptive use. Therefore, it is important to focus on how female hormones may affect resistance training responses.

OBJECTIVE

The aim of this systematic review is to identify and critically appraise current studies on the effect of the menstrual cycle and oral contraceptives on responses to resistance training.

METHODS

The electronic databases Embase, PubMed, SPORTDiscus and Web of Science were searched using a comprehensive list of relevant terms. Studies that investigated the effect of the menstrual cycle phase or oral contraceptive cycle on resistance training responses were included. Studies were also included if they compared resistance training responses between the natural menstrual cycle and oral contraceptive use, or if resistance training was adapted to the menstrual cycle phase or oral contraceptive phase. Studies were critically appraised with the McMasters Universities Critical Review Form for Quantitative Studies and relevant data were extracted.

RESULTS

Of 2007 articles found, 17 studies met the criteria and were included in this systematic review. The 17 included studies had a total of 418 participants with an age range of 18-38 years. One of the 17 studies found no significant differences in acute responses to a resistance training session over the natural menstrual cycle, while four studies did find changes. When assessing the differences in acute responses between the oral contraceptive and menstrual cycle groups, two studies reported oral contraceptives to have a positive influence, whilst four studies reported that oral contraceptive users had a delayed recovery, higher levels of markers of muscle damage, or both. For the responses to a resistance training program, three studies reported follicular phase-based training to be superior to luteal phase-based training or regular training, while one study reported no differences. In addition, one study reported no differences in strength development between oral contraceptive and menstrual cycle groups. One further study reported a greater increase in type I muscle fibre area and a trend toward a greater increase in muscle mass within low-androgenic oral contraceptive users compared with participants not taking hormonal contraceptives. Finally, one study investigated androgenicity of oral contraceptives and showed greater strength developments with high androgenic compared with anti-androgenic oral contraceptive use.

CONCLUSIONS

The reviewed articles reported conflicting findings, and were often limited by small participant numbers and methodological issues, but do appear to suggest female hormones may affect resistance training responses. The findings of this review highlight the need for further experimental studies on the effects of the menstrual cycle and oral contraceptives on acute and chronic responses to resistance training.

Hormonal Contraception and the Brain: Examining Cognition and Psychiatric Disorders

Background:

The combined oral contraceptive pill (OC), containing synthetic estrogens and progestins, is used by millions of women worldwide, yet little is known about its effects on cognition or on psychiatric disorders. The progestin component of OCs determines their androgenicity, i.e. whether the OC has androgen binding components with masculinising effects or antiandrogenic components with feminising effects.

Objective:

The present review discusses the literature surrounding OC use and cognition in healthy women. Given the important role that sex hormones play in psychiatric disorders, we also consider the influence of OCs on symptoms of schizophrenia, post-traumatic stress disorder, depression, bipolar disorder, anxiety disorders and indirectly, sleep quality.

Results:

Research has shown that while there are no differences between OC users and non-users, androgenic OCs enhance visuospatial ability and anti-androgenic OCs enhance verbal fluency. Little is known about OCs effects on other cognitive domains, such as memory and executive function. There is little research examining OC use in schizophrenia, post-traumatic stress disorder, bipolar disorder and anxiety disorders. There is some evidence that OC use is associated with depression, however the exact causality of this association remains to be verified.

Conclusion:

We maintain that future studies need to address several methodological limitations, such as separating OCs based on androgenicity to avoid the masking effects that occur when various OCs are considered as one group. As this review highlights several significant effects of OC use on the brain, the implications of OC use needs to be considered in future research.

Reviewing the cost-effectiveness of long-acting reversible contraceptive methods in an Australian context

BACKGROUND

Relative to the oral contraceptive pill, uptake of long-acting reversible contraceptive methods (LARCs) in Australia continues to be lower than might be suggested by the evidence on their clinical and economic benefits.

AIM

To undertake a critical appraisal of published economic evaluations of LARCs to assess the generalisability of their results to the Australian healthcare context.

MATERIALS AND METHODS

A search of the literature was conducted to identify studies of economic evaluations of LARCs using the Medline, Embase and PubMed databases. The quality of the studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

A total of 1009 citations were screened, from which 20 papers, typically reporting the cost per pregnancy avoided, were reviewed. The overall quality of the studies varied but was generally poor (average score of 62/100). To aid comparisons, results have been grouped under the headings IUS (all hormonal intrauterine systems), IUDs (all non-hormonal intrauterine devices), injectables (all contraceptive injections) and implants (all subdermal contraceptive implants). Overall, the results indicated that LARCs were more effective and less costly than oral contraceptives.

CONCLUSIONS

Despite evidence that LARCs represent value for money, limitations in study quality and approaches must be taken into account when applying these results to Australia. Differences in healthcare settings aside, LARCs may also have benefits beyond their effect on pregnancy that might be captured in broader analyses, such as cost-benefit analyses using willingness to pay methods. These would capture benefits beyond health, which seem to be particularly relevant to contraception.

Prescription pattern and trend of oral contraceptives in Japan: A descriptive study based on pharmacy claims data (2006 - 2014)

OBJECTIVE

The use of combined oral contraceptives (COC) as a contraceptive method is still limited in Japan, used only by 1.1% of women of reproductive age. The usage pattern of COC, such as continuation and preparation switch, between COC generations was investigated using large datasets.

METHODS

This descriptive study spanning from 2006 to 2014 used nationwide prescriptions based on administrative databases, including both reimbursed and non-reimbursed drugs. All the first-time COC users were included as a cohort. Usage patterns considering trends, continuation, and switch of COC generations were also investigated.

RESULTS

Of the 38,123 patients, the overall mean age at initial use of COC was 32.9 years. Of the first-time users, 51.2%, 23.7%, 5.6%, and 19.5% received first-, second-, third-, and fourth-generation COCs, respectively. The overall rate of continuation was 59.1%, and the rate of first-time use with switching to other generations within 180 days was 3.1%.

CONCLUSION

We revealed the actual usage of COC in Japan with frequent prescriptions of first- or fourth-generation COCs and relatively high age at initial use. Moreover, the COC continuation rate was low, and switch was limited. Further studies into its proper usage are recommended.

The association between new generation oral contraceptive pill and the development of inflammatory bowel diseases

Background/Aims

To examine the association between use of oral contraceptive pills (OCPs) and the risk of developing inflammatory bowel diseases (IBD), in a modern cohort.

Methods

A prospective nested case-control study across sites in the Asia-Pacific region was conducted; involving female IBD cases and asymptomatic controls. Subjects completed a questionnaire addressing questions related to OCP use. Primary outcome was the risk of development of IBD of those exposed to OCP versus non-exposure. Secondary outcomes were development of Crohn's disease (CD) versus ulcerative colitis (UC), and whether age of first use of OCP use may be associated with risk of IBD.

Results

Three hundred and forty-eight female IBD cases (41% CD, median age: 43 years) and 590 female age-matched controls were recruited. No significant association was found between OCP use and the risk of IBD (odds ratio [OR], 1.65; 95% confidence interval, 0.77-3.13; P=0.22), CD (OR, 1.55) or UC (OR, 1.01). The lack of association persisted when results were adjusted for age and smoking. IBD cases commenced OCP use at a younger age than controls (18 years vs. 20 years, P=0.049).

Conclusions

In this large cohort of subjects from the Asia-Pacific region, we found a modest but not significantly increased risk of developing IBD amongst OCP users.

Norethisterone Related Drug Induced Liver Injury: A Series of 3 Cases

Drug induced liver injury (DILI) is uncommon and severe forms are associated with significant morbidity and mortality. Female sex hormones (estrogens and progestogens) related DILI generally occur with estrogen component. Progesterone component related DILI are infrequently reported. Norethisterone is commonly used drug in gynecologic practice to prevent excess per vaginal bleeding. We report 3 cases of Norethisterone related DILI manifesting as significant rise of transaminases. All of these patients took Norethisterone for prolonged periods and improved completely after withdrawal of drug.